AP-Physiology
Exercise Physiology Service Enquiry + Pre-Screen
Full Name
*
First Name
Last Name
Phone Number and Email
*
Phone Number
Email- example@email.com
Local Suburb
*
Example- Hillarys
Date of Birth
*
-
Day
-
Month
Year
Day / Month / Year
Health & Injury History
Do you have any injuries, past or current?
*
Shoulders
Back
Hips
Knees
Ankles
Arms
No Injuries
Other
Do the injuries previously mentioned impact your exercise? (If yes, please provide as much specific detail of your injury as you know.)
*
Have you been told that you have any of the below by a health professional?
*
High Blood Pressure
High Cholesterol
Asthma
Arthritis
Diabetes
Osteoporosis
None of the above
Other
Exercise History & Goals
What are your primary health goals?
*
Are there any current obstacles that would prevent you from reaching your goals?
*
Have you considered a budget for achieving your health/fitness goals? ($ per week)
*
Do you have a Referral? Please state type of Referral below (example: EPC)-
*
From your GP/Specialist/Other.
Do you give consent for one of our Exercise Physiologists to contact you, and also give consent for any recommended exercises or treatment that may be discussed with you?
*
Verbal consent to treatment will be discussed in person.
What are your available days and times to perform exercise?
Private Health Fund Provider?
How did you learn or hear about me as an Exercise Physiologist?
Submit
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